After President Donald Trump announced last week that the federal government will beginfor lower prices on medicines paid for by Medicare Part B, discussion has flared once again about how best to lower drug prices overall, particularly for seniors.
What may be overlooked in all the debate is a much more immediate change that some Medicare recipients may be facing during the current 2019 open-enrollment period that ends Dec. 7.
A ruling from the Centers for Medicare and Medicaid Services (CMS) will allow Medicare Advantage plans to implement "step therapy" provisions starting in 2019. Medicare Advantage is a replacement for traditional Medicare. It's administered through private insurers and covers original Medicare parts A and B and often Part D prescription drug coverage and extras that traditional Medicare doesn't cover, such as dental and vision. About a third of Medicare recipients choose Medicare Advantage plans.
With step therapy, patients must try cheaper medicines first before they're allowed to move to newer, costlier drugs. Critics of the policy and patient advocates often call this "fail first" therapy because the expectation is that patients must fail on certain drugs before they get access to one that may work best for them, explained Dr. David Charles, chairman of the advocacy group Alliance for Patient Access.
The bulk of Medicare Advantage step therapies are likely to happen under Medicare Part B, in which doctors are reimbursed for drugs they administer on-site such as chemotherapy and other injectable medicines. These are usually expensive drugs used to treat serious conditions.
Step therapy rules can also restrict prescription medications as well, especially high-priced drugs to treat conditions such as hepatitis, asthma and diabetes.
This strategy has been used for years by private insurers and employer-sponsored plans. Proponents rightly point to the cost savings involved when less expensive but equally effective medicines are used in place of costlier therapies.
What's significant now is that seniors, those likeliest to have chronic conditions and other health concerns that require expensive drugs, may now be subject to step therapy regimens that they may be unprepared to deal with. What's more, sometimes a patient's health may deteriorate as she goes through the steps.
"In and of itself, step therapy is not a bad thing," said Charles. "It's something we're taught in medical school -- if someone has borderline high blood pressure, of course you try diet and exercise before writing a prescription. The problem comes when there are abuses."
Take rheumatoid arthritis. Charles has seen patients in step therapy who have been denied Food and Drug Administration-approved medicine to stop flair-ups before trying less expensive but often less effective drugs. While those patients try the cheaper drugs, they're subjected to pain, and worse, joint injury that may never be repaired. He has seen multiple sclerosis patients in the same predicament.
Cancer, of course, is the most extreme case, said Charles, when timing is most important and new therapies are always on the horizon.
In a survey last year by the doctors' social network site SERMO, 64 percent of 3,050 U.S. physician respondents said an insurer rejected what they had prescribed once a month, even after a patient had failed step therapy.
For consumers in the midst of the Medicare open enrollment and considering Medicare Advantage plans, here's what you can do to manage this most recent change:
Check for more paperwork
The CMS change came so late in the year that many insurers may not have included step therapy in the annual notice of change they send to plan members before open enrollment, said Leslie Fried, senior director of the Center for Benefits Access at the National Council on Aging. She advises seniors to check both mail and email for an addendum to plan changes in existing coverage.
Call and ask
More important, added Fried, call whichever Medicare Advantage plans you're considering, even if it's the plan you already have, and ask if it's taking advantage of the new step therapy rule and what that means for your individual prescription drug coverage.
Review the appeals process carefully
The memo from CMS describing the rule change includes a discussion concerning an exception policy and the appeals process. But details are still vague, said Fried. "What confidence do we have that this will work for seriously ill people in a timely way?"
Again, the best defense for now is calling the Medicare Advantage plans you're considering. Ask not only if they're adopting step therapy but how exactly the exemption and appeals process will work under the policy you're considering. Your doctors can also help you determine what a policy change may mean for coverage of further treatment.
Includes reporting from The Associated Press